Every finding on record at Best Hospice Provider, Inc.

Based on interview and record review, the Hospice Agency (HA) failed to notify the Physician (MD) regarding the wound for one (Patient 3) out of 4 sampled patients. This failure resulted in inconsistent wound care and inability to re-evaluate the plan of care. This failure also had the potential to result in unnecessary discomfort and decreased quality of life. --- During a review of Patient 3s ";Hospice Nursing Initial Comprehensive Admission Assessment," for benefit period dated 7/25/24 to 10/22/24, the assessment indicated Patient 3 resided in an assisted living facility (ALF) and had a Start of Care (SOC) date with HA on 7/25/24 with multiple diagnoses including malignant neoplasm of rectosigmoid junction (cancer of the rectum) and pressure ulcer of sacral (tailbone area), stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer). The admission assessment also indicated, ";Assess skin integrity...Coccyx (tailbone) pressure ulcer closed...Encouraged to reposition every 2 hours." During a review of Patient 3s ";Hospice Nursing Clinical Note," dated from 7/28/24 to 8/14/24, the notes indicated Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 assessed and provided different wound care to Patient 3s wound on tailbone area. RN 1 and LVN 1 did not notify or obtain wound care orders from MD. During a review of Patient 3s ";Home Health Agency Care Note (care communication form of ALF)," dated 7/29/24, 8/2/24 and 8/10/24, the notes indicated RN 1 provided wound care to Patient 3 and again did not notify MD. During a telephone interview on 10/4/24 at 11:00 a.m. with LVN 1, LVN 1 stated she observed Patient 3 had a new wound on sacrum upon removal of an old dressing. LVN 1 further stated there was no order for wound care on patient 3s electronic clinical record and decided to provide the wound care. LVN stated she was unable to recall whether she communicated Patient 3s wound to MD. During a telephone interview on 10/4/24 at 11:36 a.m. with RN 1, RN 1 stated she had been the primary RN case manager for Patient 3. RN 1 stated she sent the order obtained from MD through the agencys text communication application and office clinicians should have entered the order on patient 3s electronic record. During a concurrent interview and record review on 10/4/24 at 1:45 p.m. with Director Patient Care Services (DPCS), Patient 3s electronic clinical record was reviewed. DPCS stated she did not find wound care orders for Patient 3. DPCS also stated that she expected licensed nurses should notify and obtain wound care orders from the MD per agencys protocol. DPCS confirmed the agencys text communication was an application available on all clinicians (field licensed nurses, doctors, supervisors, and the office clinical team) phones, and field licensed nurses could obtain care orders from MD. During a review of retrieved information from the agencys text communication application, dated 7/25/24 until 8/17/24, the information indicated RN 1 and LVN 1 did not obtain order from MD and did not notify the office clinical team of Patient 3s wound care. During a concurrent interview and record review on 10/15/24 at 11:30 a.m. with Licensed Vocational Nurse (LVN) 2. A photocopy of communication between LVN 1 and LVN 2 was reviewed. LVN 2 stated receiving the text message from LVN 1 on 8/14/2024, regarding Patient 3s wound. LVN 2 further stated he called to obtain wound care order from Patient 3s MD. LVN 2 also stated he spoke with one of the clinical supervisors about the order, but he couldnt recall the name of the person he spoke with. LVN 2 did not document this communication in Patient 3s clinical record. During an interview on 10/15/24 at 12:00 p.m. with LVN 3 and RN 2, both stated they were unaware of Patient 3s wound or wound care needs and there was no physican order for wound care. They also stated that they did not receive a phone call from LVN 2 regarding Patient 3s wound care order on 8/14/2024. Additionally, RN 2 stated that LVN 1 only informed LVN 2 about Patient 3s wound because LVN 1 did not use the agencys text communication application.During a review of agencys policy and procedure (P&P) titled ";Skin Care/Wound Management Program Policy," dated January 2024, the P&P indicated, ";Physician Orders for Wound Care...6. A physician order is required for any cleansing, medication, treatment, dressing, or a ";leave to open air". Physician orders are input into the hospices medication administration record...After physician orders are received by the Skilled Nurse, the Plan of Care is updated with the newly acquired order." During a review of agencys P&P titled, ";Verification of Physician Orders," dated May 2023, the P&P indicated, ";To ensure that accurate physician orders are obtained in accordance with applicable law and regulation...Orders will be obtained from a licensed physician for care and services to be provided to hospice patients...2.All telephone orders...will be documented by the staff receiving the order, indicated by staff signature and credentials, and cosigned by the physician...3.Orders will be documented on a form provided by Best Hospice Providers Inc, dated and signed by the professional receiving the order."

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence of a current/comprehensive Medication Profile: Patient #7: The IDG POC dated 01/31/24 included "Oxygen 2-5 lpm p.r.n." This was not included on the Medication Profile.

Upon patient record review, 1 of 14 (Patient #11) did not contain evidence that the Hospice had developed an individualized written Plan of Care for each patient. The Plan of Care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The Plan of Care must include all services necessary for the palliation and management of the terminal illness and related conditions: Patient #11: The admitting RN documents in her 12/29/23 SOC Assessment that the patient has an indwelling Foley Catheter 16F/5cc balloon." A verbal order was written on 12/29/23 for, "Foley 18 F/5cc. Change Q month." Foley order was not updated to the next subsequent IDG note of 01/03/23; nor did the order delineate 'who' was to change such Foley Q month.

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #7: The IDG POC dated 01/31/24 included, "Right upper extremity and right groin wounds. Cleanse with wound cleanser, pack with Polysporin/Silvadeen, apply dressing with oil emulsion, cover with non-stick gauze, kerlix, then tape." There was no frequency ordered for this intervention.

Upon patient record review, 2 of 14 (Patients #1 and 2) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs: Patient #1: During Surveyor-attended home visit on 02/13/24 it was noted that the patient had the DME of: Hospital bed. This was not included on the POC. Patient #2: During Surveyor-attended home visit on 02/13/24 it was noted that the patient had the DME of: 1) Bed; 2) Walker; 3) Commode; and 4) Shower chair. These DME were not included on the POC.

Upon patient record review, 1 of 14 (Patient #8) did not contain evidence that a revised Plan of Care included information from the patient's updated comprehensive assessment(s): Patient #8: The SOC/POC dated 12/08/23 ordered, "Aide visits at a frequency of 1x per week x13 weeks; effective 12/12/23." A separate verbal order was also obtained on 12/08/23, for "Aide services declined." Yet, the subsequent IDG Meeting notes dated 12/20/23, 01/03/24, and 01/17/24 all continued to include this Aide service and visit frequency of, "1x per week x13 weeks."

Upon personnel record review, 1 of 11 (Personnel #7) did not contain evidence that an Aide Skills Competency Assessment had been conducted for the Aide, which included all CMS subject matter. An Aide Skills Competency Assessment was conducted on 04/01/2022. However the following was not evaluated for: Competency related to the physical, emotional, and developmental needs of, and ways to work with, the populations served by the Hospice.

Upon patient record review 1 of 14 (Patient #2) did not contain documented evidence that a Hospice Aide provided care/services only as are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #2: During Surveyor-attended home visit on 02/12/24, the Aide was interviewed, and reported having assisted the patient, upon Aide arrival at the home, in Active/Passive Range of Motion; prior to the patient attempting to get out of bed and ambulate. This intervention was not assigned on the current Aide POC. The current Aide POC assigned a complete bed bath. The Aide provided a shower at this same home visit.

Upon patient record review, 1 of 14 (Patient #10) did not contain evidence that each patient record contained: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 There must be evidence that the Hospice Election Statement reflects that: The effective date of the Hospice Election, may be no earlier than the dated Election Statement. An individual/representative may not designate an effective date that is retroactive to the date the Hospice Benefit Election was signed up for: Patient #10: SOC was 12/28/23. However, the Election Statement was not dated by the patient's representative until 01/12/24.

Upon patient record review, 1 of 14 (Patient #7) did not contain evidence that all entries were clear: Patient #7: The SOC POC dated 12/07/23 included, "Oxygen 2-5 l.p.m., p.r.n." The IDG POC dated 01/31/24 included, "Oxygen 2 l.p.m., p.r.n., also effective 12/07/23." This is unclear clinical documentation, as to what the dose of Oxygen was at the SOC 12/07/23.

Upon Inpatient contract review, 1 of 1 (Sequoia Living GIP/RIP) did not contain evidence that it contained the contract requirements of: 1) The Hospice patient's inpatient clinical record must include a record of all inpatient services furnished, and events regarding care that occurred at the facility; 2) That a copy of the Discharge Summary shall be provided to the Hospice at the time of discharge; and 3) That a copy of the inpatient clinical record is available to the Hospice at the time of discharge. This contract did not include: That a copy of the Discharge Summary shall be provided to the Hospice at the time of inpatient discharge.

It is required that the hospice designates a registered nurse member of the IDG to ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician (if any); the patient or patient representative; the primary caregiver in accordance with the patient’s needs. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 6 (33%) clinical records reviewed, the hospice did not ensure the registered nurse followed the plan of care as ordered. Record 1: The patient’s date of election was 9/3/2022. A physician’s order on 12/1/2022 ordered RN/LVN 3 x week. During the week 12/18/2022-12/24/2022, there was one nursing visit on 12/22/2022. There was no documented evidence of a second or third nursing visit or documented reasons for the missed visits. During the week 12/25/2022-12/31/2022, there was one nursing visit on 12/27/2022. There was no documented evidence of a second or third nursing visit or documented reasons for the missed visits. Record 4: The patient’s date of election was 11/23/2022. The plan of care dated 11/23/2022 ordered RN/LVN 1 x week. During the week 12/18/2022-12/24/2022, there was no documented evidence of a nursing visit or documented reason for the missed visit. The Administrator was interviewed on 1/3/2023 and agreed, there was no documented evidence the missing nursing visits were completed and there were no documented reasons for the missed visits. Record 1: The patient’s date of election was 9/3/2022. A physician’s order on 12/1/2022 ordered RN/LVN 3 x week. During the week 12/18/2022-12/24/2022, there was a nursing visit 12/22/2022. There was no documented evidence of a second or third nursing visit or documented reasons for the missed visits. During the week 12/25/2022-12/31/2022, there was a nursing visit on 12/27/2022. There was no documented evidence of a second or third nursing visit or documented reasons for the missed visits. Record 4: The patient’s date of election was 11/23/2022. The plan of care dated 11/23/2022 ordered RN/LVN 1 x week. During the week 12/18/2022-12/24/2022, there was no documented evidence of a nursing visit or documented reason for the missed visit. The Administrator was interviewed on 1/3/2023 and agreed, there was no documented evidence the missing nursing visits were completed and there were no documented reasons for the missed visits.

It is required that each patient’s individualized written plan of care reflects patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records and interviews. In 2 of 2 (100%) clinical records reviewed with wounds, the hospice did not ensure the plans of care reflected patient and family goals and interventions based on problems identified in comprehensive assessments. Record 1: The patient’s date of election was 9/3/2022. The Registered Nurse (RN) assessment on 12/22/2022 was reviewed and revealed wound care provided by the RN to right lateral foot: NS, pat dry, apply medihoney, calcium alginate, covered with optifoam. The plan of care was reviewed between 12/2/2022-1/4/2023. There was no documented evidence of an order for the wound care or planned interventions for the right lateral foot wound. Record 3: The patient’s date of election was 12/5/2022. The Registered Nurse (RN) assessment on 12/20/2022 was reviewed and revealed wound care provided by the RN to coccyx: clean with NS and foam dressing. The plan of care was reviewed between 12/20/2022-1/4/2023. There was no documented evidence of an order for the wound care or planned interventions for the sacral wound. The Alternate Administrator was interviewed on 1/4/2023 and agreed, there was no documented evidence of wound care orders or planned interventions for the wounds identified. Record 1: The patient’s date of election was 9/3/2022. The Registered Nurse (RN) assessment on 12/22/2022 was reviewed and revealed wound care provided by the RN to right lateral foot: NS, pat dry, apply medihoney, calcium alginate, covered with optifoam. The plan of care was reviewed between 12/2/2022-1/4/2023. There was no documented evidence of an order for the wound care or planned interventions for the right lateral foot wound. Record 3: The patient’s date of election was 12/5/2022. The Registered Nurse (RN) assessment on 12/20/2022 was reviewed and revealed wound care provided by the RN to coccyx: clean with NS and foam dressing. The plan of care was reviewed between 12/20/2022-1/4/2023. There was no documented evidence of an order for the wound care or planned interventions for the sacral wound. The Alternate Administrator was interviewed on 1/4/2023 and agreed, there was no documented evidence of wound care orders or planned interventions for the wounds identified.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. THIS IS A CONTUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. In 4 of 4 (100%) clinical records reviewed with a hospice aide ordered, the hospice did not ensure the hospice aide followed the plan of care as ordered. Record 1: The patient’s date of election was 9/3/2022. A physician’s order dated 12/1/2022 ordered a hospice aide 2 x week. During the weeks 12/18/2022-12/24/2022 and 12/25/2022-12/31/2022 there was no documented evidence of hospice aide visits or documented reasons for the missed visits. Record 2: The patient’s date of election was 11/10/2022. The plan of care dated 11/10/2022 ordered a hospice aide 2 x week. During the weeks 12/18/2022-12/24/2022 and 12/25/2022-12/31/2022 there was no documented evidence of hospice aide visits or documented reasons for the missed visits. Record 3: The patient’s date of election was 12/5/2022. The plan of care dated 12/13/2022 and 12/21/2022 ordered a hospice aide 3 x week. During the weeks 12/18/2022-12/24/2022 and 12/25/2022-12/31/2022 there was no documented evidence of hospice aide visits or documented reasons for the missed visits. Record 4: The patient’s date of election was 11/23/2022. A physician’s order dated 12/5/2022 ordered a hospice aide 3 x week. During the weeks 12/18/2022-12/24/2022 and 12/25/2022-12/31/2022 there was no documented evidence of hospice aide visits or documented reasons for the missed visits. The Administrator was interviewed on 1/3/2023 and agreed, there was no documented evidence the missing hospice aide visits were completed and there were no documented reasons for the missed visits. The Administrator stated, “I talked to the aide who said she sees the patient but didn’t document it.” Record 1: The patient’s date of election was 9/3/2022. A physician’s order dated 12/1/2022 ordered a hospice aide 2 x week. During the weeks 12/18/2022-12/24/2022 and 12/25/2022-12/31/2022 there was no documented evidence of hospice aide visits or documented reasons for the missed visits. Record 2: The patient’s date of election was 11/10/2022. The plan of care dated 11/10/2022 ordered a hospice aide 2 x week. During the weeks 12/18/2022-12/24/2022 and 12/25/2022-12/31/2022 there was no documented evidence of hospice aide visits or documented reasons for the missed visits. Record 3: The patient’s date of election was 12/5/2022. The plan of care dated 12/13/2022 and 12/21/2022 ordered a hospice aide 3 x week. During the weeks 12/18/2022-12/24/2022 and 12/25/2022-12/31/2022 there was no documented evidence of hospice aide visits or documented reasons for the missed visits. Record 4: The patient’s date of election was 11/23/2022. A physician’s order dated 12/5/2022 ordered a hospice aide 3 x week. During the weeks 12/18/2022-12/24/2022 and 12/25/2022-12/31/2022 there was no documented evidence of hospice aide visits or documented reasons for the missed visits. The Administrator was interviewed on 1/3/2023 and agreed, there was no documented evidence the missing hospice aide visits were completed and there were no documented reasons for the missed visits. The Administrator stated, “I talked to the aide who said she sees the patient but didn’t document it.”

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 4 (75%) clinical records reviewed, the hospice did not ensure the hospice medical director provided written certification of the terminal illness. Record 2: The patient’s date of election was 11/10/2022. There was no documented evidence the hospice medical director or physician designee provided a written certification of the terminal illness and narrative with clinical eligibility to support the prognosis of six months or less. Record 3: The patient’s date of election was 12/5/2022. There was no documented evidence the hospice medical director or physician designee provided a written certification of the terminal illness and narrative with clinical eligibility to support the prognosis of six months or less. Record 4: The patient’s date of election was 11/23/2022. There was no documented evidence the hospice medical director or physician designee provided a written certification of the terminal illness and narrative with clinical eligibility to support the prognosis of six months or less. The Administrator was interviewed on 1/4/2023 and agreed, there was no documented evidence hospice medical director or physician designee provided a written certification of the terminal illness and narrative with clinical eligibility to support the prognosis of six months or less. The Administrator was interviewed on 1/4/2023 and stated, “we haven’t corrected these yet, we are working on getting education set up for the medical director.” Record 2: The patient’s date of election was 11/10/2022. There was no documented evidence the hospice medical director or physician designee provided a written certification of the terminal illness and narrative with clinical eligibility to support the prognosis of six months or less. Record 3: The patient’s date of election was 12/5/2022. There was no documented evidence the hospice medical director or physician designee provided a written certification of the terminal illness and narrative with clinical eligibility to support the prognosis of six months or less. Record 4: The patient’s date of election was 11/23/2022. There was no documented evidence the hospice medical director or physician designee provided a written certification of the terminal illness and narrative with clinical eligibility to support the prognosis of six months or less. The Administrator was interviewed on 1/4/2023 and agreed, there was no documented evidence hospice medical director or physician designee provided a written certification of the terminal illness and narrative with clinical eligibility to support the prognosis of six months or less. The Administrator was interviewed on 1/4/2023 and stated, “we haven’t corrected these yet, we are working on getting education set up for the medical director.”

It is required that all entries in the patient record are legible, complete, and appropriately authenticated and dated by the person performing the care/service in accordance with hospice policy and with currently acceptable standards of practice. (L679) The hospice has a means to authenticate entries or to identify the author of each entry. (L679) 1. If the hospice uses electronic records, electronic authentication utilizes a user ID and password protection. In 3 of 4 (75%) clinical records reviewed, the hospice did not ensure all entries in the medical records were appropriately authenticated and dated in accordance with hospice policy. Agency policy, “Clinical/Service Data Collection, Policy No. C:2-033.1” stated in part, “Entries into the clinical/service record will be made on the day care/service is provided to the patient. The clinical/service note will include signature of clinician/technician and his/her credentials. Signature authorization of clinical/service documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents).” Agency policy, “Verification of physician orders, Policy No. H:2-032.1” stated in part, “Signed orders will be in the clinical record within 30 days of initiation of care.” Record 1: The patient’s date of election was 9/3/2022. The Registered Nurse assessment on 12/16/2022 was reviewed and revealed there was no documented evidence the Registered Nurse signed and authenticated the documentation. The Registered Nurse assessment on 12/22/2022 was reviewed and revealed there was no documented evidence the Registered Nurse signed and authenticated the documentation. The Registered Nurse assessment on 12/27/2022 was reviewed and revealed there was no documented evidence the Registered Nurse signed and authenticated the documentation. Record 2: The patient’s date of election was 11/10/2022.The plan of care dated 11/10/2022 was reviewed and revealed the primary care physician, the hospice medical director, did not sign the orders until 1/4/2023, 55 days after being admitted to the agency. Record 3: The patient’s date of election was 12/5/2022. The Spiritual assessment on 12/16/2022 was reviewed and revealed there was no documented evidence the Chaplain signed and authenticated the documentation. Record 4: The patient’s date of election was 11/23/2022. The Licensed Vocational Nurse (LVN) assessment on 12/29/2022 was revealed and revealed there was no documented evidence the LVN signed and authenticated the documentation. The hospice aide visit note on 12/19/2022 was reviewed and revealed there was no documented evidence the hospice aide signed and authenticated the documentation. The hospice aide visit note on 12/21/2022 was reviewed and revealed there was no documented evidence the hospice aide signed and authenticated the documentation. The plan of care dated 11/23/2022 was reviewed and revealed the primary care physician, the hospice medical director, did not sign the orders until 1/4/2023, 42 days after being admitted to the agency. The Administrator was interviewed on 1/4/2023 and agreed, there was no documented evidence the entries in the medical records were appropriately authenticated and dated in accordance with hospice policy. The Administrator stated, “the staff should be signing off on the visits the same day they are done.” The Administrator stated, “the medical director did not sign the plan of care until today” for the records identified. Agency policy, “Clinical/Service Data Collection, Policy No. C:2-033.1” stated in part, “Entries into the clinical/service record will be made on the day care/service is provided to the patient. The clinical/service note will include signature of clinician/technician and his/her credentials. Signature authorization of clinical/service documentation will include the staff member’s name and credentials (as specified on professional licenses and/or certification documents).” Agency policy, “Verification of physician orders, Policy No. H:2-032.1” stated in part, “Signed orders will be in the clinical record within 30 days of initiation of care.” Record 1: The patient’s date of election was 9/3/2022. The Registered Nurse assessment on 12/16/2022 was reviewed and revealed there was no documented evidence the Registered Nurse signed and authenticated the documentation. The Registered Nurse assessment on 12/22/2022 was reviewed and revealed there was no documented evidence the Registered Nurse signed and authenticated the documentation. The Registered Nurse assessment on 12/27/2022 was reviewed and revealed there was no documented evidence the Registered Nurse signed and authenticated the documentation. Record 2: The patient’s date of election was 11/10/2022.The plan of care dated 11/10/2022 was reviewed and revealed the primary care physician, the hospice medical director, did not sign the orders until 1/4/2023, 55 days after being admitted to the agency. Record 3: The patient’s date of election was 12/5/2022. The Spiritual assessment on 12/16/2022 was reviewed and revealed there was no documented evidence the Chaplain signed and authenticated the documentation. Record 4: The patient’s date of election was 11/23/2022. The Licensed Vocational Nurse (LVN) assessment on 12/29/2022 was revealed and revealed there was no documented evidence the LVN signed and authenticated the documentation. The hospice aide visit note on 12/19/2022 was reviewed and revealed there was no documented evidence the hospice aide signed and authenticated the documentation. The hospice aide visit note on 12/21/2022 was reviewed and revealed there was no documented evidence the hospice aide signed and authenticated the documentation. The plan of care dated 11/23/2022 was reviewed and revealed the primary care physician, the hospice medical director, did not sign the orders until 1/4/2023, 42 days after being admitted to the agency. The Administrator was interviewed on 1/4/2023 and agreed, there was no documented evidence the entries in the medical records were appropriately authenticated and dated in accordance with hospice policy. The Administrator stated, “the staff should be signing off on the visits the same day they are done.” The Administrator stated, “the medical director did not sign the plan of care until today” for the records identified.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician: a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 2 (50%) clinical records reviewed with a discharge from hospice revealed the hospice did not ensure that the discharge summary was provided to the attending. Record 5: The patient’s date of election was 6/23/2022. The discharge was reviewed and revealed the patient was discharged-no longer terminally ill on 12/17/2022. There was no documented evidence the discharge summary was sent to the attending. The Business Office Manager was interviewed on 1/3/2023 and stated, “there’s no record of this one being sent to the attending.” The Administrator was interviewed on 1/3/2023 and agreed, there was no documented evidence the discharge summary was sent to the attending. Record 5: The patient’s date of election was 6/23/2022. The discharge was reviewed and revealed the patient was discharged-no longer terminally ill on 12/17/2022. There was no documented evidence the discharge summary was sent to the attending. The Business Office Manager was interviewed on 1/3/2023 and stated, “there’s no record of this one being sent to the attending.” The Administrator was interviewed on 1/3/2023 and agreed, there was no documented evidence the discharge summary was sent to the attending.

It is required that the hospice conducts and documents a patient-specific comprehensive assessment that identifies the patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. The assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by review of clinical records and interview which revealed issues with completion of initial and comprehensive assessments of patients in the following areas: Failure of the hospice Interdisciplinary Group to demonstrate completion of the psychosocial, spiritual and bereavement assessment, as part of the initial comprehensive assessment, within five (5) calendar days after the election of hospice care (HCPC.9.I/L523); Failure of the hospice Interdisciplinary Group to ensure the initial comprehensive assessment included a review of all of the patient's medications for adverse effects, significant side effects and contraindications (HCPC.15.I/L530); and Failure of the hospice Interdisciplinary Group to demonstrate completion of an initial bereavement assessment (HCPC.13.I/L531). The cumulative effect and scope of these deficiencies could negatively impact the organization’s ability to identify and meet the care needs of the patients and ensure continuity of care and service coordination.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by clinical records review and interview. 4 of 4 (100%) records reviewed revealed the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any) did not complete the initial comprehensive assessment no later than five (5) calendar days after patients' election of hospice care. Clinical Record 6: The patient elected hospice care on 11/23/22. The initial nursing assessment was completed 11/23/22. Review of the clinical record revealed no evidence of the initial psychosocial, spiritual and bereavement assessments. The Hospice Plan of Care and/or initial nursing assessment on admission 11/23/22 did not include evidence of refusal of these services. There are no documented IDG meeting reviews to see if the missing assessments were discussed. During a joint clinical review and interview on 12/13/22, the LVN/Marketer/Director of Services who was designated to review records by the Director Patient Care/Administrator Designee stated, "The psychosocial, spiritual and bereavement assessments are missing and there was no communication notes to explain the missing assessments." Clinical Record 5: The patient elected hospice care on 12/5/22. The initial nursing assessment was completed on 12/5/22. Review of the clinical record revealed no evidence of the initial psychosocial, spiritual and bereavement assessments. The Director acknowledged the initial nursing assessment did not contain any documentation that the patient had refused these services. There was further acknowledgement that there were no documented IDG meetings to validate whether these missing assessments were discussed. Clinical Record 3: The patient elected hospice care on 11/10/22. The initial nursing assessment was completed on 11/10/22. Review of the clinical record revealed no evidence of the initial psychosocial, spiritual and bereavement assessments. The Hospice Plan of Care and/or initial nursing assessment on admission 11/10/22 did not document refusal of these services and there was no documented IDG meetings to determine if there was discussion of the missing assessment. Clinical Record 2: The patient elected hospice care on 9/3/22. The initial nursing assessment was completed on 9/3/22. Review of the clinical record revealed the initial psychosocial assessment was completed 9/18/22 with no documentation to support why the assessment was completed later than five (5) calendar days after the election of hospice care. There were no spiritual and bereavement assessments completed within five days of the patient's election of the benefit. During a joint clinical review and interview 12/13/22, the LVN/Marketer/Director of Services confirmed there was no documented evidence of completed psychosocial, spiritual and bereavement assessments completed within 5 calendar days from the date of election of hospice services, and there was no evidence of communication notes to explain the missing assessments. The Hospice Plan of Care and/or initial nursing assessments did not contain documentation these visits were refused and there were no documented IDG meetings which discussed these missing assessments. During joint clinical review and interview on 12/13/22, the LVN/Marketer/Director of Services acknowledged the psychosocial, spiritual and bereavement assessments were missing.

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current: prescription and over-the-counter (OTC) drugs, supplements, herbal remedies and other alternative treatments that could affect drug therapy. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 4 (25%) records reviewed of patients who elected hospice after the implementation of the agency's new electronic medical record program August/September 2022 revealed the hospice did not ensure the initial comprehensive assessment included a review of all of the patient's medications for adverse effects, significant side effects and contraindications. . Clinical Record 5: was reviewed and identified the patient elected hospice on 12/5/22 with no documented terminal diagnosis. Review of the record on 12/12/22 revealed missing verbal and/or signed physician's orders for medications and missing medications on the medication profile. During interview 12/12/2022 with the LVN/Marketer/Director of Services present, the admission RN (Staff 4) stated, “When I completed the nursing assessment on 12/5/22, I did not call the doctor to get medication orders...I did not get a list of medications that the son said he was giving his mother....I did not do the hospice plan of care or get medication orders and put them into the clinical record because I did not know how to do the paperwork". A joint review of the medication profile on 12/13/22 revealed the following medications with the “start date of 12/5/22, Morphine Sulfate, Lorazepam, Ipratropium Albuterol, Haloperidol, Hyoscyamine Sulfate, Senna Lax, Bisacodyl, and Acetaminophen”. There was no evidence of written or verbal physician’s orders for the medications and no IDG plan of care. These medications were not present on the medication profile during the joint clinical record review conducted with the LVN/Director of Services/Marketer on 12/12/22. During an interview on 12/13/22, the LVN/Marketer/Director of Services, stated, “These are our comfort kit medications...Something does not add up, how was the admission nurse able to take a picture of these medications if she was the first hospice nurse to see and assess the patient during the RN admission 12/5/22”. In addition, during an interview on 12/13/22, the admission RN (Staff 4) stated, “Yes, yesterday after we spoke I entered the patient’s medications onto the medication profile with a start date of 12/5/22...I was able to add the medications since I took a picture of the medications when I was doing the assessment on 12/5/22...I did not call the physician to get medication orders”.

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 4 (100%) records reviewed of patients who elected hospice after the implementation of the agency's new electronic medical record program August/September 2022, revealed the hospice did not ensure to complete an initial bereavement assessment as part of the comprehensive assessment. Clinical Record 6: was reviewed and identified the patient elected hospice care on 11/23/22. Review of the clinical record revealed a no evidence of a bereavement assessment included as part of the initial assessment. Clinical Record 5 was reviewed and identified the patient elected hospice care on 12/5/22. Review of the clinical record revealed a no evidence of a bereavement assessment included as part of the initial assessment. Clinical Record 3 was reviewed and identified the patient elected hospice care on 11/10/22. Review of the clinical record revealed a no evidence of a bereavement assessment included as part of the initial assessment. Clinical Record 2 was reviewed and identified the patient elected hospice care on 9/3/22. Review of the clinical record revealed a no evidence of a bereavement assessment included as part of the initial assessment. During a joint clinical record review and an interview on 12/13/22, the LVN/Marketer/Director of Services designated by the Administrator/Director Patient Care Designee to review clinical records stated, "The bereavement assessment is not documented in the clinical record". During joint clinical record review and interview 12/13/22, the LVN/Marketer/Director of Services designated by the Administrator/Director Patient Care Designee to review clinical records stated, "The bereavement assessment is not documented in the clinical record".

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by clinical record review, document review and interview. which revealed the following issues with the development and implementation of patients’ interdisciplinary care plans: Failure of the hospice Interdisciplinary Group to develop a documented patient plan of care (HCPC.18.I/L537); Failure of the hospice Interdisciplinary Group to develop patient plans of care that specified the hospice care and services necessary to meet the specific needs of the patients and families as identified in the comprehensive assessment (HCPC.18.I/L538); Failure of the hospice Interdisciplinary Group to ensure hospice care and services were provided and coordinated to meet the patient's care needs (HCPC.1.I/L539); Failure of the hospice to designate a registered nurse member of the interdisciplinary group to provide coordination of care and ensure continuous assessment of the patient's and family's needs and implementation of the interdisciplinary plan of care (HCPC.19.I/L540) and Failure of the Interdisciplinary Group to document review and revision of patients’ care plans as frequently as the patient's condition requires, but no less frequently than every 15 calendar days (HCPC.22.I/L552). As a result of substantial non-compliance with the conditions of participation including the failure of the hospice to ensure the management and oversight of its administrative and clinical operations, all of which could pose actual or potential serious injury, harm, impairment or death to patients served by the hospice, a determination of IMMEDIATE JEOPARDY was made.

It is required that the hospice designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 4 (25%) applicable records reviewed of patients who elected hospice after the implementation of the agency's new electronic medical record program August/September 2022, the hospice did not develop a plan of care. Clinical Record 5 was reviewed and identified the patient elected hospice on 12/5/22 with no documented terminal diagnosis. The patient was hospitalized 12/3/22 through 12/5/22 with “hypertensive urgency, UTI, weakness, dementia.” The patient was discharged home on 12/5/22 with the son as the sole caregiver. Review of the record on 12/12/22 revealed missing verbal and/or signed physician's orders for medications, hospice care and services, and missing the IDG plan of care. In addition, a review of the record revealed the patient had verbal and non-verbal signs and symptoms of pain during the initial nursing assessment 12/5/22 and a subsequent nursing visit on 12/8/22. The initial nursing assessment completed 12/5/22 by the registered nurse (RN) (staff #4) documented, “Verbal Pain level 5-6, facial grimacing, frequent intermittent pain worsened by change in position and movement, general body pain, FLACC non-verbal assessment of pain level 5, distracted, occasional moaning, tense, distressed, and shortness of breath level 2 when agitated”. During an interview on 12/12/2022, with the Director of Services present, the admission RN (Staff 4) stated, “When I completed the nursing assessment on 12/5/22, I did not call the doctor to get medication orders... I did not get a list of medications that the son said he was giving his mother....I did not do the hospice plan of care or get medication orders and put them into the clinical record because I did not know how to do the paperwork". During interview 12/12/22, the Medical Director stated, “The nurse did not call to get medication orders or to give me a report on the patient... The only information I received regarding this patient was the hospital physician notes and hospital medications sent to me from the hospice intake department on 12/3/22...I do not recall if this patient was discussed at the 12/9/22 IDG meeting”. Unable to interview the caregiver son. During interview 12/12/22, the Director Patient Care/Administrator Designee stated the son did not answer the phone and went directly to voice mail. A follow up review of the clinical record on 12/13/22 revealed a documented list of "comfort kit" medications on the medication profile with a “start date of 12/5/22” with no written or verbal physician’s orders for the medications and no IDG plan of care. These medications were not present on the medication profile in the clinical record during joint clinical record review on 12/12/22 with the Director of Services/Marketer who was designated by the Director Patient Care/Administrator Designee. During a follow up interview 12/13/22, the admission RN (Staff 4) stated, “Yes, yesterday after we spoke, I entered the patient’s medications onto the medication profile with a start date of 12/5/22”, “I was able to add the medications since I took a picture of the medications when I was doing the assessment on 12/5/22” and “I did not call the physician to get medication orders”. Review of the medication profile on 12/13/22 revealed the following medications: "start date of 12/5/22, Morphine Sulfate, Lorazepam, Ipratropium Albuterol, Haloperidol, Hyoscyamine Sulfate, Senna Lax, Bisacodyl, and Acetaminophen”. During interview 12/13/22, the LVN/Marketer/Director of Services, stated, “These are our comfort kit medications...Something does not add up, how was the admission nurse able to take a picture of these medications if she was the first hospice nurse to see and assess the patient during the RN admission 12/5/22”. Subsequent Nursing visit note completed by the RN case manager (Staff 5) 12/8/22 documented, “aggravated and agitated, intermittent pain, achy dull pain, visually restless, combative, short of breath level 1, difficult to console or comfort, uneasy, tense, worsened by movement, and appears to be seeing things”. During interview 12/12/22, the RN (Staff 5) stated, “I did not call the medical director to report symptoms and to obtain medication orders on 12/8/22”. The clinical record revealed no documented IDG/IDT review meetings to discuss and review the plan of care. The electronic medical record (EMR) included an “IDG Review” format which was not dated, did not include IDT/IDG attendees and included a blank “IDG notes” section. During an interview on 12/12/22, the LVN/Marketer/Director of Services stated, “An IDG meeting was held on 12/9/22 and I was there along with the nurse, medical director, social worker and chaplain...This is a new EMR system that we rolled out August/September 2022”. During interview on 12/12/22, the Medical Director stated, “Yes, I do attend IDG meetings at the hospice with the rest of the team”. Additionally, during interview on 12/12/22, the hospice consultant stated, “I checked with the EMR company and found out we cannot see the IDG Review forms since the staff did not fill out and complete the forms”.

It is required that the plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. This standard was not met as evidenced by a review of clinical records and interviews. In 3 of 4 (75%) applicable records reviewed of patients who elected hospice after the implementation of the agency's new electronic medical record program August/September 2022, the hospice Interdisciplinary Group (IDG) failed to ensure a hospice plan of care was developed with physician orders for medications and services necessary to meet the specific needs of the patient and family, as identified in the comprehensive assessments. Clinical Record 5: The patient was hospitalized 12/3/22 through 12/5/22 with “hypertensive urgency, UTI, weakness, dementia”, discharged home 12/5/22 with the son as the sole caregiver. Hospice care was elected on 12/5/22 with no documented terminal diagnosis. Review of the record on 12/12/22 revealed missing verbal and/or signed physician's orders for medications, no medication profile, and no plan of care was initiated by the IDG for the patient. During interview 12/12/2022 with the Director of Services present, the admission RN (Staff 4) confirmed that the doctor was not called to review and obtain orders for medications the caregiver was administering to the patient. The nurse stated she did not know how to complete the hospice paperwork. During interview on 12/12/22, the Medical Director stated, “The nurse did not call to get medication orders or to give me a report on the patient...The only information I received regarding this patient was the hospital physician notes and hospital medications sent to me from the hospice intake department on 12/3/22." The medical director stated he could not recall if the patient was discussed at the 12/9/22 IDG meeting. A follow up review of the clinical record on 12/13/22 revealed a documented list of "comfort kit" medications on the medication profile with a “start date of 12/5/22” with no written or verbal physician’s orders for the medications and no IDG plan of care. These medications were not present on the medication profile in the clinical record during joint clinical record review on 12/12/22 with the Director of Services/Marketer. A review of the clinical record revealed no documented IDG/IDT review meetings to discuss and review the plan of care. The electronic medical record (EMR) included an “IDG Review” format which was not dated, did not include IDT/IDG attendees and included a blank “IDG notes” section. Clinical Record 2: identified the patient elected hospice on 9/3/22. Review of the clinical record revealed the initial nursing assessment completed on 9/3/22 documented "plan of care discussed with medical director". Medications listed on the Medication Profile included a start date of 9/3/22. The "Hospice Plan of Care" dated 9/3/22 was signed by the RN only and included the medications that were listed from the Medication Profile. There were no physician's orders for medications, either verbal or signed by the physician, and no documented evidence of "IDG Review" meetings. There was no evidence that the social worker and counselor, as part of the Interdisciplinary Group, established the hospice plan of care. Clinical Record 3: The patient elected hospice on 11/10/22. Review of the clinical record revealed the initial nursing assessment completed on 11/10/22 documented "plan of care discussed with medical director". Medications listed on the Medication Profile included a start date of 11/10/22. The "Hospice Plan of Care" was dated 11/10/22, was signed by the RN only and included the medications that were listed from the Medication Profile. There were no physician's orders for medications, either verbal or signed by the physician, and no documented evidence of "IDG Review" meetings. There was no evidence that the social worker and counselor, as part of the Interdisciplinary Group, established the hospice plan of care. Clinical Record 6: The patient elected hospice on 11/11/10/22. Review of the clinical record revealed the initial nursing assessment completed on 11/23/22 documented "plan of care discussed with medical director". Medications listed on the Medication Profile included a start date of 11/23/22. The "Hospice Plan of Care" was dated 11/23/22 was signed by the RN only and included the medications that were listed from the Medication Profile. There were no physician's orders for medications, either verbal or signed by the physician, and no documented evidence of "IDG Review" meetings. There was no evidence that the social worker and counselor, as part of the Interdisciplinary Group, established the hospice plan of care. During joint clinical record review and interview on 12/13/22, the LVN/Marketer/Director of Services stated, "there are no verbal or signed physician's orders, the medical director did not sign the Hospice Plan of Care, and there is no documentation to show the social worker and counselor established the plan of care."

It is required that the hospice designates an Interdisciplinary Group (IDG) composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient/family facing terminal illness and bereavement. The IDG, in its entirety, supervises the care and services provided to the patient and family. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 4 (25%) applicable records reviewed of patients who elected hospice after the implementation of the agency's new electronic medical record program August/September 2022, the hospice did not ensure the Interdisciplinary Group provided and documented evidence of supervision and coordination of hospice care and services provided to the patient and family. Clinical Record 5: identified the patient elected hospice on 12/5/22 with no documentation of terminal diagnosis. The patient was hospitalized 12/3/22 through 12/5/22 with “hypertensive urgency, UTI, weakness, dementia.” The patient was discharged home on 12/5/22 with the son as the sole caregiver. A review of the record revealed the patient had verbal and non-verbal signs and symptoms of pain during the initial nursing assessment on 12/5/22 and a subsequent nursing visit on 12/8/22. The initial nursing assessment completed 12/5/22 by the registered nurse (RN) (staff #4) documented, “verbal Pain level 5-6, facial grimacing, frequent intermittent pain worsened by change in position and movement, general body pain, FLACC non-verbal assessment of pain level 5, distracted, occasional moaning, tense, distressed, and shortness of breath level 2 when agitated.” During an interview on 12/12/2022, with the Director of Services present, the admission RN (Staff 4) stated she did not call the doctor to get medication orders and did not obtain a list of medications which were being administered by the caregiver son. During interview on 12/12/22, the Medical Director confirmed that he did not receive a call from the nurse who admitted the patient and could not recall if this patient was discussed at the 12/9/2022 IDG meeting which he attends. A follow up review of the clinical record on 12/13/22 revealed a documented list of "comfort kit" medications on the medication profile with a “start date of 12/5/22” with no written or verbal physician’s orders for the medications and no IDG plan of care. These medications were not present on the medication profile in the clinical record during joint clinical record review on 12/12/22 with the Director of Services/Marketer who was designated by the Director Patient Care/Administrator Designee. During a follow up interview on 12/13/22, the admission RN (Staff 4) confirmed a list of medications were entered onto the medication profile subsequently. “I was able to add the medications profile since I took a picture of the medications when I was doing the assessment on 12/5/22. The medication listed with a start date of 12/5/2022 included Morphine Sulfate, Lorazepam, Ipratropium Albuterol, Haloperidol, Hyoscyamine Sulfate, Senna Lax, Bisacodyl, and Acetaminophen. During interview on 12/13/22, the LVN/Marketer/Director of Services stated: “These are our comfort kit medications... Something does not add up. How was the admission nurse able to take a picture of these medications if she was the first hospice nurse to see and assess the patient during the RN admission on 12/5/22”. Subsequent nursing visit note completed by the RN case manager (Staff 5) on 12/8/22 documented the patient was, “aggravated and agitated, intermittent pain, achy dull pain, visually restless, combative, short of breath level 1, difficult to console or comfort, uneasy, tense, worsened by movement, and appears to be seeing things”. During interview on 12/12/22, the RN (Staff 5) stated: “I did not call the medical director to report symptoms and to obtain medication orders on 12/8/22”. The clinical record revealed no documented IDG/IDT review meetings to discuss and review the plan of care. The electronic medical record (EMR) included an “IDG Review” format which was not dated, did not include IDT/IDG attendees and included a blank “IDG notes” section. During an interview on 12/12/22, the LVN/Marketer/Director of Services stated, “An IDG meeting was held on 12/9/22 and I was there along with the nurse, medical director, social worker and chaplain. This is a new EMR system that we rolled out August/September 2022”. During interview 12/12/22, the Medical Director stated, “Yes, I do attend IDG meetings at the hospice with the rest of the team”. Additionally, during interview on 12/12/22, the hospice consultant stated, “I checked with the EMR company and found out we cannot see the IDG Review forms since the staff did not fill out and complete the forms.”

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs; ensure the implementation of the interdisciplinary plan of care. Hospice care and services provided to patients and families follow the individualized plan of care established by the hospice IDG in collaboration with the attending physician, patient and primary caregiver. This requirement was not met as evidenced by clinical record review, document review and interview. 1 of 4 (25%) records reviewed revealed the hospice did not ensure a Registered Nurse was designated to coordination patient care and ensure implementation of the interdisciplinary plan of care. Clinical Record 5: The patient was hospitalized 12/3/22 through 12/5/22 with “hypertensive urgency, UTI, weakness, dementia”, discharged home 12/5/22 with the son as the sole caregiver. Hospice care was elected on 12/5/22 with no documented terminal diagnosis. Review of the record on 12/12/22 revealed missing verbal and/or signed physician's orders for medications, no medication profile, and no plan of care was initiated by the IDG for the patient. On 12/5/22, the RN case manager was not available, another RN (Staff 4) was assigned to conduct the initial nursing assessment for the patient (Record 5) admission to hospice care. Review of the clinical record revealed no evidence of the initial psychosocial, spiritual and bereavement assessments. During interview 12/12/2022 with the Director of Services present, the admission RN (Staff 4) confirmed that the doctor was not called to review medications and to obtain orders for medications the caregiver was administering to the patient. During interview on 12/12/22, the Medical Director stated, “The nurse did not call to get medication orders or to give me a report on the patient...The only information I received regarding this patient was the hospital physician notes and hospital medications sent to me from the hospice intake department on 12/3/22." The medical director stated he could not recall if the patient was discussed at the 12/9/22 IDG meeting.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires but no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records and interviews. In 7 of 7 (100%) applicable records reviewed of patients who elected hospice after the implementation of the agency's new electronic medical record program August/September 2022, the hospice Interdisciplinary Group failed to document the individualized plan of care reviews no less frequently than every 15 calendar days. Clinical Record 6: was reviewed and identified the patient elected hospice on 11/23/22. Review of the record on 12/12/22 revealed no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care. The electronic medical record (EMR) included an “IDG Review” format which was not dated, did not include IDG attendees and included a blank “IDG notes” section. Clinical Record 5: was reviewed and identified the patient elected hospice on 12/5/22 with no documented terminal diagnosis. Review of the record on 12/12/22 revealed no documented evidence of Interdisciplinary Group review of the plan of care during the meeting scheduled on 12/9/22. Review of the record revealed the patient had verbal and non-verbal signs and symptoms of pain during the initial nursing assessment on 12/5/22 and a subsequent nursing visit on 12/8/22. During interview on 12/12/22, the Medical Director stated, “The nurse did not call to get medication orders or to give me a report on the patient...The only information I received regarding this patient was the hospital physician notes and hospital medications sent to me from the hospice intake department on 12/3/22... I do not recall if this patient was discussed at the 12/9/22 IDG meeting”. Review of the clinical record revealed no documented IDG/IDT review meetings to discuss and review the plan of care. The electronic medical record (EMR) included an “IDG Review” format which was not dated, did not include IDT/IDG attendees and included a blank “IDG notes” section. During interview on 12/12/22, the LVN/Marketer/Director of Services stated, “An IDG meeting was held on 12/9/22 and I was there along with the nurse, medical director, social worker and chaplain. This is a new EMR system that we rolled out August/September 2022”. Clinical Record 1: was reviewed and identified the patient elected hospice on 5/6/22. Review of the record revealed no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care since the implementation of the new electronic medical record (EMR) system during August/September 2022. The clinical record included an “IDG Review” format which was not dated, did not include IDG attendees and included a blank “IDG notes” section. Clinical Record 4: was reviewed and identified the patient elected hospice on 6/23/22. Review of the record revealed no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care since the implementation of the new electronic medical record (EMR) system during August/September 2022. The clinical record included an “IDG Review” format which was not dated, did not include IDG attendees and included a blank “IDG notes” section. Clinical Record 7: was reviewed and identified the patient elected hospice on 6/25/22 and expired on 12/7/22. Review of the record revealed no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care since the implementation of the new electronic medical record (EMR) system during August/September 2022. The clinical record included an “IDG Review” format which was not dated, did not include IDG attendees and included a blank “IDG notes” section. Clinical Record 2: was reviewed and identified the patient elected hospice on 9/3/22. Review of the record revealed no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care. The electronic medical record (EMR) included an “IDG Review” format which was not dated, did not include IDG attendees and included a blank “IDG notes” section. Clinical Record 3: was reviewed and identified the patient elected hospice on 11/10/22. Review of the record revealed no documented evidence of Interdisciplinary Group (IDG) reviews of the plan of care. The electronic medical record (EMR) included an “IDG Review” format which was not dated, did not include IDG attendees and included a blank “IDG notes” section. During interview on 12/12/22, the Medical Director stated, “Yes, I do attend IDG meetings at the hospice with the rest of the team”. Additionally, during interview 12/12/22, the hospice consultant stated, “I checked with the EMR company and found out we cannot see the IDG Review forms since the staff did not fill out and complete the forms”. During interview on 12/12/22, the LVN/Marketer/Director of Services stated, “IDG meeting are held every two weeks and I attend along with the nurse, medical director, social worker and chaplain. This is a new EMR system that we rolled out August/September 2022”.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group, included in the plan of care, permitted to be performed under state law and regulation and consistent with the hospice aide training. This standard was not met as evidenced by a review of clinical records and interviews. In 1 of 7 (14%) records reviewed, the hospice did not ensure the hospice aide was compliant with the assigned visit frequency. Clinical Record 2: was reviewed and identified the hospice aide visit frequency of two times a week. Review of the clinical record revealed one extra hospice aide visit the week of 9/2/22. There was no evidence of communication with the physician to increase the frequency of aide visits. During an interview on 12/12/22, the LVN/Marketer/Director of Services stated, "Yes, there are three hospice aide visit notes the week of 9/2/22 and I do not see orders or a plan of care update to cover the extra aide visit note the week of 9/2/22".

It is required that the hospice organizes, manages, and administers its resources to provide the hospice care and services to patients, families, and caregivers necessary for the palliation and management of the terminal illness and related conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This Condition of Participation was not met as evidenced by review of clinical records and interviews which revealed failure by the Governing Body and Administrator/Director Patient Care Services (DPCS) to ensure that the management and oversight of administrative and clinical operations of the hospice were occurring on a day-to-day basis, and that the individuals charged with providing oversight were qualified and completing the duties associated with their roles (HSLG.3.I/L651). The cumulative effect and scope of this deficiency could negatively impact the agency's ability to provide safe, quality care that meets the needs of patients, families, and caregivers for the palliation and management of the terminal illness and related conditions. Failure of the administrator to be responsible for the day-to-day operations and provide oversight and management of patient care services and personnel. Failure of the administrator to identify another individual to assume her assigned duties. The Administrator/Director Patient Care has been out of the country for the past two weeks. The Administrator/Director Patient Care Designee was not informed he was to provide management of patient care services and personnel. During interview 12/12/22, the LVN/Marketer/Director of Services stated, "The Administrator/Director Patient Care has been out of the country for the past 2 weeks", "I am overseeing operations and remotely communicating with the Administrator/Director Patient Care when needed", and "(Staff 2) is the Administrator/Director Patient Care Designee". Additionally during interview 12/13/22, the LVN/Marketer/Director of Services stated, "The Administrator/Director Patient Care is flying home today and we will be unable to reach her during the 16 hour flight". The Administrator/Director Patient Care Designee was available by phone and arrived at the agency the afternoon on 12/12/22 and morning of 12/13/22. During interview 12/12/22, the Administrator/Director Patient Care Designee stated, "I did not know the Administrator/Director Patient Care was out of the country and that I was responsible for the clinical management of the agency", "I was not notified I needed to cover the clinical management during the past two weeks", "I work full time at another job and now going to school as well", " I did not know about the patient's (Record 5) admission and that the nurse (Staff 4) was assigned to do the admission", and "I do not attend IDG meetings at the agency". During interview 12/12/22, the LVN/Marketer/Director of Services stated, "I cover the intake department and general operations management since the Administrator/DPCS has been out of the country for the past two weeks", "On 12/5/22, the RN case manager was not available so I assigned another RN (Staff 4) to do the initial nursing assessment for the patient (Record 5) admission on 12/5/22, The RN case manager completed a follow up visit on 12/8/22 and is on the calendar to visit the patient weekly", and "I have been attending the IDG meetings every 2 weeks".

It is required that a qualified administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. If the administrator is not available, another individual is assigned the administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by interviews, which revealed failure of the Administrator/DPCS to communicate and coordinate with the Administrator/Director Patient Care Designee to assume her assigned duties when she was out of the country for the past two weeks. The site visit commenced on 12/12/2022. During the entrance conference it was communicated that the Administrator was not at the agency. The LVN/Marketer/Director of Services was interviewed on 12/12/2022 and stated: "The Administrator/Director Patient Care Services has been out of the country for the past 2 weeks. I am overseeing operations and remotely communicating with the Administrator/Director Patient Care Services (DPCS) when needed. (Staff 2) is the Administrator/Director Patient Care Designee". When asked about the availability of the Administrator, the Director of Services stated that the Administrator/DPCS will be unavailable during the 16-hour flight" time. The Administrator/Director Patient Care (DPCS) Designee was available by phone and arrived at the agency the afternoon of 12/12/22 and was subsequently present at the agency the morning of 12/13/22. During interview the Administrator/DPCS designee stated: "I did not know the Administrator/DPS was out of the country and that I was responsible for the clinical management of the agency. I was not notified I needed to cover the clinical management during the past two weeks. I work full time at another job and now going to school as well." During further interview, the LVN/Marketer/Director of Services stated: "I cover the intake department and general operations management since the Administrator/DPCS has been out of the country for the past two weeks. On 12/5/22, the RN case manager was not available, so I assigned another RN (Staff 4) to do the initial nursing assessment for the patient (Record 5) admission on 12/5/22. The RN case manager completed a follow up visit on 12/8/22 and is on the calendar to visit the patient weekly. I have been attending the IDG meetings every 2 weeks". The DPCS Designee was interviewed about the patient admission (Record 5) and stated he did not know about the admission or that the nurse (Staff 4) was assigned to do the admission. The DPS confirmed that he does not participate in IDG meetings. Failure of the administrator to be responsible for the day-to-day operations and provide oversight and management of patient care services and personnel. Failure of the administrator to identify another individual to assume her assigned duties. The Administrator/Director Patient Care has been out of the country for the past two weeks. The Administrator/Director Patient Care Designee was not informed he was to provide management of patient care services and personnel. During interview 12/12/22, the LVN/Marketer/Director of Services stated, "The Administrator/Director Patient Care has been out of the country for the past 2 weeks", "I am overseeing operations and remotely communicating with the Administrator/Director Patient Care when needed", and "(Staff 2) is the Administrator/Director Patient Care Designee". Additionally during interview 12/13/22, the LVN/Marketer/Director of Services stated, "The Administrator/Director Patient Care is flying home today and we will be unable to reach her during the 16 hour flight". The Administrator/Director Patient Care Designee was available by phone and arrived at the agency the afternoon on 12/12/22 and morning of 12/13/22. During interview 12/12/22, the Administrator/Director Patient Care Designee stated, "I did not know the Administrator/Director Patient Care was out of the country and that I was responsible for the clinical management of the agency", "I was not notified I needed to cover the clinical management during the past two weeks", "I work full time at another job and now going to school as well", " I did not know about the patient's (Record 5) admission and that the nurse (Staff 4) was assigned to do the admission", and "I do not attend IDG meetings at the agency". During interview 12/12/22, the LVN/Marketer/Director of Services stated, "I cover the intake department and general operations management since the Administrator/DPCS has been out of the country for the past two weeks", "On 12/5/22, the RN case manager was not available so I assigned another RN (Staff 4) to do the initial nursing assessment for the patient (Record 5) admission on 12/5/22", "The RN case manager completed a follow up visit on 12/8/22 and is on the calendar to visit the patient weekly", and "I have been attending the IDG meetings every 2 weeks".

It is required that the hospice medical director or physician designee reviews the clinical information for each patient being evaluated for admission and provides written certification that it is anticipated that the patient's life expectancy is six months or less if the illness runs its normal course. The physician considers the following when making this determination: the primary terminal condition, related diagnosis(es), if any, current subjective and objective medical findings, current medication and treatment orders, and information about the medical management of any of the patient's conditions unrelated to the terminal illness. This standard was not met as evidenced by a review of clinical records and interviews. 4 of 4 (100%) applicable records reviewed of patients who elected hospice after the implementation of the agency's new electronic medical record program August/September 2022, the hospice failed to ensure initial certification requirements were completed. During joint clinical review and interview 12/13/22, the LVN/Marketer/Director of Services who was designated by the Administrator/Director of Patient Care Designee stated: "The initial certifications are missing in the clinical record. The agency rolled out the new electronic medical record program in August/September 2022 and follow up training needs to be done." Clinical Record 2: the patient elected hospice on 9/3/22. Review of the initial certification form in the clinical record revealed a missing medical director's narrative to support the prognosis of six months or less. The record did include a documented verbal certification from the medical director and included a signed initial certification from the attending physician. Clinical Record 3: the patient elected hospice on 11/10/22. Review of the clinical record revealed a missing verbal and/or signed initial certification from the medical director and missing the medical director's narrative to support the prognosis of six months or less. Clinical Record 5: the patient elected hospice on 12/5/22. Review of the clinical record revealed a missing verbal and/or signed initial certification from the medical director and missing the medical director's narrative to support the prognosis of six months or less. Clinical Record 6: the patient elected hospice on 11/23/22. Review of the clinical record revealed a missing verbal and/or signed initial certification from the medical director and missing the medical director's narrative to support the prognosis of six months or less. During joint clinical review and interview 12/13/22, the LVN/Marketer/Director of Services who was designated by the Administrator/Director of Patient Care Designee stated, "The initial certifications are missing in the clinical record" and "The agency rolled out the new electronic medical record program in August/September 2022 and follow up training needs to be done".

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescriptions and over the counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by document, clinical record review, and interview. 1 of 3 (33%) records revealed the hospice did not ensure a review of all medications the patient was taking had occurred, at the time of the comprehensive assessment. Record #67114: The Benefit Period beginning 1/16/2022, diagnosis included Dementia and Hypertension. The nursing visit note dated 1/19/2022, identified that the patient had a temperature, stating "Temperature 101.4, caregiver had given patient Tylenol." The medication profile had not been updated to include a review of the new medication Tylenol. The policy "Safe Effective Use of Medication (Policy No. H:5-002.1) (revised November 2017) read in part"... [Agency] will encourage patient and family/caregiver participation in his/her own hospice care and will explain the correct administration of medications by the patient or family/caregiver, as ordered by the physician or purchased over the counter. The family/caregivers will be assessed on their knowledge and skill related to medication administration. Documentation of patient and family/caregiver instruction in the clinical record will include updating medication profile." During the exit conference, it was stated by the Director of Nurses that the medication profile should have been updated as part of the comprehensive assessment

It is required that a hospice aide provides services ordered by the Interdisciplinary Group included in the plan of care; permitted to be performed under state law and regulation and is consistent with the hospice aide training. This standard was not met as evidenced by document, record review and interview. 1 of 1 (100%) records of patients receiving Hospice Aide services revealed documented evidence that the Hospice Aide was not compliant with following the assigned Hospice Aide Care Plan per policy. Record #26: The Certification of Terminal Illness (CTI) signed 1/20/2022 for the Start of Care, 1/15/2022 through 4/14/2022, diagnosis included Chronic diastolic (congestive) heart failure, End stage renal disease, Type 2 diabetes mellitus with diabetic neuropathy. The "Aide Care Plan” dated 1/15/2022, under the section titled, “Aide Care Plan Instructions: Personal Care" instructed the aide to "Assist to Dress, Skin Care," and "Partial Bath/Shower Per Visit." The aide visit, dated 1/25/2022, under the section "Personal Care" documented "Foot Care," Nail Care" and "Complete Shower" without being instructed by the RN. The policy "Orientation of Hospice Personnel to Assigned Responsibilities" (Policy No H:3-005.1 (revised November 2017), read in part"...A hospice aide assignment sheet will be competed, reviewed with the hospice aide, and signed by both the clinical and the hospice aide. Return demonstration will be requested as appropriate. Each patient will receive care in accordance with the plan of care and related instructions. The hospice aide assignment sheet will correlate with the orders on the plan of care. This will be returned to the office and incorporated in the clinical record." During the exit conference, it was stated by the Director of Nurses that that the Aide should have followed the care plan and in-services will be provided to ensure compliance.

It is required that the hospice maintains a written comprehensive emergency preparedness program that uses an “all-hazards” approach specific to the geography and population served; and includes strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural or man-made disasters, emerging infectious diseases (EIDS) that place the health and safety of patients and employees at risk, and other anticipated emergencies that could affect the hospice’s ability to provide care. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by an interview with the Administrator during which it was revealed that there was no hazard vulnerability analysis completed or approved by the Governing Board for 2021 for the communities/counties that the agency serves for 2021. During interview the Administrator stated that there were emergency events that had occurred in 2021 that either impacted or had the potential to impact patients and/or staff including, but not limited to, infectious disease (specifically COVID-19), rolling blackouts, wildfires, and flooding. The Administrator asked if information from county emergency management websites could be referenced in the future development of a plan for the agency which the site visitor validated.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care, in accordance with CMS §418.24–the elements of the hospice care election statement. This standard was not met as evidenced by a review of clinical records and interview with the agency RN during which it was revealed that in 2 of 6 (33%) of clinical records did not have an initial comprehensive assessment completed no later than five (5) calendar days after the election of hospice care. Record #77179: Start of Care (SOC) 5/5/2021, 1st Benefit Period, Diagnosis Parkinson’s, Transfer to another hospice 7/8/2021: The Social Worker (SW) initial assessment was documented six days after the start of care. The SW documented the initial bereavement assessment over 30 days after the SOC. There was no documentation that the physician was notified of or approved initial assessment delays. Record #44269: Start of Care (SOC) 1/23/2021, 3rd Benefit Period, Diagnosis CVA/Stroke, Transfer out of service area 4/1/2021: The Social Worker (SW) initial assessment was documented six days after the start of care. The Chaplain's initial assessment and the initial bereavement assessment were documented nine days after the SOC. There was no documentation that the physician was notified of or approved initial assessment delays.

It is required that the hospice develops, implements, and maintains an effective, ongoing, hospice-wide, data-driven quality assurance and performance improvement program (QAPI). THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by a review of quality documentation binder and interview of the Administrator, which revealed that the hospice governing body failed to appoint/designate a responsible clinician for the responsibility of operating the QAPI program [HQPI.2.I/L576]; the agency failed to conduct performance improvement activities which track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospice [HQPI.7.I/L569/THIS WAS A CONTINUING PRIOR REQUIRED ACTION]; the Governing Body failed to ensure that an ongoing program for quality improvement and patient safety was implemented, and maintained, and is evaluated annually [HSLG.2.I/L574] and failure of the Governing Body to ensure implementation of continuous quality assessment and performance improvement [HSLG.3.I/L 651] The cumulative effect of these deficiencies has resulted in the hospice agency's inability to provide quality care for the Condition of Participation CFR 418.58, Quality Assessment and Performance Improvement. The collective deficient practice illustrated not having a process in place to ensure quality patient care.

It is required that performance improvement activities track adverse patient events, analyze the causes, and implement preventive action and mechanisms that include feedback and learning throughout the hospice. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by an interview with the Administrator and agency RN and review of a binder labeled "QI PLANS 2020, 2021" A cover sheet on the binder indicated that it contained the following information: Monthly Clinical Record Reviews, Falls/Incidents, and Complaints; Quarterly PAC meetings, Annual Governing Body Meeting with agency evaluation; Quarterly Performance Improvement Plans and QA Meetings; IDG Meetings and HIS measures every 14 days; Annual Competency Evaluation/Peer Evaluations, Volunteer Appreciation and Bereavement Program Memorial activities along with Quarterly Hospice Quality Measures. The binder contained Tabs labeled 1 through 4 and one labeled Performance Plans," but there was no content behind these tabs. The agency RN also provided a binder containing blank clinical record review tools and stated that he had not seen or used these tools to review any clinical records since his date of hire (2/1/2021). The agency Administrator said that he would reach out to a QA RN to determine if there was a record of any active or discharge record audits completed between February 2021 and December 2021 as was included in the plan of correction, which was written following the initial deemed accreditation site visit on 1/7/2021. At the time of the site visit exit conference, the Administrator confirmed that there were no chart audits completed per the plan of correction. The site visitor did see spreadsheets labeled "patient infection logs" in a folder provided by the agency RN on 1/5/2021. The Administrator stated no records documented patient falls or adverse events, staff infections (including COVID exposures), patient or staff complaints, performance improvement plans, or analysis of hospice quality measures. Of note, the agency Administrator informed the site visitor at the start of the survey that the office administrative assistant was out of the office due to a "COVID exposure" but confirmed no process for documenting or tracking staff infections, including COVID.

It is required that one or more individual(s) is appointed by the governance as responsible for operating the QAPI program. This standard was not met as evidenced by interview with the agency Administrator and an agency RN. The RN stated that he "helps out in the office occasionally" but is not responsible for the operation of the QAPI program. The Administrator stated that the RN was hired with the "hope that he would work out" as the leader of the QAPI program. The Administrator stated that there was no documentation in governing body meeting minutes designating a person or committee responsible for QAPI program operations; "It was just something that we intended to work on together as an office when we had time."

It is required that the hospice documents and maintains an effective infection control program that protects patients, families, visitors, and hospice staff by preventing and controlling infections and communicable diseases. The infection control program includes education of employees, contracted providers, patients, families, and other caregivers in infection control and how timely communication occurs with hospice staff, patients, families, and visitors about infection prevention and control issues, including their role in preventing the spread of infections and communicable diseases through daily activities. This standard was not met as evidenced by a review of personnel records and interview. 2 of 4 (50%) records did not include education of the agencies infection control program intended to protect patients, families, visitors, and hospice staff from the prevention and spread of infections and communicable diseases. Staff ID #37322: Date of Hire 7/23/2021, AIDE: The employee personnel record did not include any documentation of new hire education provided including training specific to the agency’s infection control program and practices. Staff ID #49457: Date of Hire 6/20/2021, Chaplain/Bereavement Coordinator: The employee personnel record did not include any documentation of new hire education provided including training specific to the agency’s infection control program and practices. The agency Administrator verified that there were no additional records to review prior to the exit conference and that infection control education was missing for the above records.

It is required that Medical Social Services are provided per the plan of care. This standard was not met as evidenced by a review of clinical records and interview. 2 of 6 (33%) records reviewed, social work visits were not performed according to the frequencies ordered by the Interdisciplinary Group (IDG), under the direction of a physician, in the patient’s plan of care/plan of care updates. Record #60400: Start of Care (SOC) 5/27/2021, 6th Benefit Period, Diagnosis COPD, Transfer to another hospice 7/25/2021: Social Worker (SW) visit frequency orders in the patient’s plan of care and plan of care updates from SOC to Transfer indicate that SW visits are to occur weekly. There is only one SW visit documented in the patient’s record in June 2021 after the initial SW evaluation visit. Record #77179: Start of Care (SOC) 5/5/2021, 1st Benefit Period, Diagnosis Parkinson’s, Transfer to another hospice 7/8/2021: Plan of Care Orders/updates from 5/27/2021 include orders for SW visits to occur twice weekly. SW visits are documented weekly after 6/6/2021, with no missed visits documented. There are no SW visits or missed visits documented from 7/1/2021 to 7/25/2021, the date of transfer.

It is required that counseling services include spiritual counseling. The hospice provides an assessment of the patient’s and family’s spiritual needs. Spiritual counseling to meet spiritual needs is provided in accordance with the patient’s and family’s acceptance of the services and in a manner consistent with the patient and family beliefs and desires. The hospice advises the patient and family of spiritual counseling services and documents the acceptance or refusal of services. The hospice also makes all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or others who can support the patient’s spiritual needs. This standard was not met as evidenced by a review of clinical records and interview. 1 of 6 (17%) records reviewed, spiritual counseling visits were not performed according to the patient’s and family’s acceptance of the services and according to the frequencies ordered by the Interdisciplinary Group (IDG), under the direction of a physician, in the patient’s plan of care/plan of care updates. Record #77179: Start of Care (SOC) 5/5/2021, 1st Benefit Period, Diagnosis Parkinson’s, Transfer to another hospice 7/8/2021: All Plan of Care Orders/updates from SOC to patient transfer indicate chaplain visits are to be performed weekly. There was no documented evidence of an initial spiritual assessment or refusal of chaplain visits.

It is required that Volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services provided to patients/families are in a defined role and under the supervision of a designated hospice employee. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. THIS IS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidence by an interview with the Administrator and clinical record review, which revealed the hospice failed to document and demonstrate viable and ongoing efforts to recruit and retain volunteers [HCDT.30.I/L645/THIS IS A CONTINUING PRIOR REQUIRED ACTION] and the agency failed to provide volunteer services used in day-to-day administrative and/or direct patient care roles[HSRM.21.I/L645]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to provide quality care for the Condition of Participation CFR 418.78, Volunteers. The collective deficient practice illustrated not having a process to ensure the provision of Volunteer Services to all patients.

It is required that volunteers are used in day-to-day administrative and/or direct patient care roles. Volunteer services are noted in the plan of care and documented in the patient record, including the time spent. This standard was not met as evidenced by a review of clinical records and interview. 2 of 2 (100%) applicable clinical records for patients that have accepted Volunteer Services, a volunteer plan of care was developed without a documented order by the Interdisciplinary Group (IDG), under the direction of a physician, in the patient’s plan of care/plan of care updates. Record #60400: Start of Care 5/27/2021, 6th Benefit Period, Diagnosis COPD, Transfer to another hospice 7/25/2021: Volunteer Coordinator documented an assessment and development of a plan of care on 6/16/2021 without a physician order. There were no volunteer visits documented as performed. Record #77179: Start of Care 5/5/2021, 1st Benefit Period, Diagnosis Parkinson’s, Transfer to another hospice 7/8/2021: Volunteer Coordinator documented assessment and development of a plan of care on 6/18/2021 without a physician order. There were no volunteer visits documented as performed.

It is required that the hospice documents and demonstrates viable and ongoing efforts to recruit and retain volunteers. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by an interview with the Administrator and a review of Agency policy. Agency policy, "Volunteer Services," reads in part, "The Volunteer Coordinator will document ongoing efforts to recruit, train, and retain volunteers." During interview, the Administrator stated "there is no Volunteer Program" and currently "there is no Volunteer Coordinator or volunteers."

It is required the hospice’s governance (or designated person(s) so functioning) assumes full legal authority and responsibility for the organization’s overall management and operation, provision of care and services and ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually. THIS IS A CMS CONDITION LEVEL CITATION. This Condition was not met as evidenced by clinical record review, personnel record review and interview, which revealed the absence of oversight by the Administrator/Owner and the Director of Patient Care Services/Alternate Administrator which revealed a Condition level deficiency in which the agency failed to implement an ongoing performance improvement and patient safety program that is defined, implemented, maintained, and evaluated annually [HQPI.I.D/L559 [L569/L574/L576, L651]; a Condition level deficiency for failure of the agency to provide volunteer services to patients and families under the supervision of a designated hospice employee [HCDT.21.I/L641 [L644/L645]; failure of the hospice governance to provide management and operations of the the agency as no person was assigned the responsibility or duties of Director of Patient Care Services or Alternate Administrator in the absence of the employee of record who has been out of the country and “unavailable” all of 2021 through the time of the site visit [HSLG.3.I/L 651]; failure of the agency to develop agency-specific hazard vulnerability analysis approved by the Governing Board for 2021 [HSEP.2.D/E-6H]; failure of the agency to provide infection control program education to newly hired staff [HIPC.1.D/L 582]; failure of the agency to ensure clinical records included signed copies of the notice of patient rights and the hospice election statement [HSIM.3.I/L 673]; failure of the agency to assess clinical competencies [HSRM.14.I/L663]; and failure of the agency to document results of a criminal background check prior to clinician providing independent care delivery [HSRM.16.I/L 796]. The cumulative effect of these deficiencies has resulted in the hospice agency's inability to provide quality care for the Condition of Participation CFR 418.100, Organization and Administration of Services. The collective deficient practice illustrated a systemic failure of not having processes to ensure quality patient care.

It is required that a qualified Administrator is appointed by and reports to the governing body and is responsible for day-to-day hospice operation. The Hospice Administrator informs the governing body about ongoing operations, including patient care delivery issues and QAPI activities. If the Administrator is not available, another individual is assigned the Administrator’s duties and responsibilities as defined in policy and procedure. This standard was not met as evidenced by an interview with the agency Administrator. It was revealed that patient care delivery issues and QAPI activities were not documented as reviewed during Governing Body meetings. The site visitor was provided with four (4), 1-page documents titled QAPI Quarter 1, QAPI Quarter 2, QAPI Quarter 3, and QAPI Quarter 4. Each document contained what appeared to be an agenda of bullet-pointed topics that would be discussed in the meeting. The documents were signed and dated by attendees, including the Administrator, Hospice Medical Director, agency RN, and other staff members. The document did not include any discussion, specific analysis of patient care delivery issues or QAPI activities, no input from attendees, and no outcomes or action items resulting from the meeting. The Administrator informed the Site Visitor that the Director of Patient Care Services(DPCS)/Alternate Administrator of record with the state and appointed by the Governing Body had been out of the country for the entire year of 2021 remains “unavailable” at the time of the site visit. The Administrator stated that there is no person currently assigned the responsibility or duties of DPCS or Alternate Administrator and that "finding a replacement has been challenging."

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services, and, as necessary, provides in-service training and education programs where required. The hospice has written policies and procedures describing the method(s) of assessing competency and maintains a written description of the in-service training provided during the previous 12 months. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of personnel records and Agency policy. Agency policy, "Initial Competency Assessment," reads in part, "The organization ensures that the competency of all personnel is assessed on hire, prior to providing care to organization patients. …Personnel will be given the appropriate job category orientation checklist…When the initial competency assessment is completed, it will be reviewed by the preceptor and the supervisor.” 1 of 4 (25%) records reviewed revealed that clinical competencies were not assessed per Agency policy. Staff ID #49457: Date of Hire 6/20/2021, Chaplain/Bereavement Coordinator: The Administrator stated that there was no record that the employee had an initial competency assessment completed for both job roles assigned-Chaplain or Bereavement Coordinator.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes signed copies of the notice of patient rights and the hospice election statement. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of clinical records and interview. 2 of 6 (33%) records reviewed did not include signed copies of the notice of patient rights and the hospice election statement for the episode of care reviewed. Record #44269: Start of Care (SOC) 1/23/2021, 3rd Benefit Period, Diagnosis CVA/Stroke, Transfer out of service area 4/1/2021. The patient clinical record, electronic or paper copies, did not include any signed admission documentation verifying notice of patient rights and hospice election for SOC 1/23/2021. The patient was readmitted to the hospice on 1/23/2021 after being released from the hospital. The last signed notice of patient rights and signed hospice election statement in the patient’s record were confirmed by the agency RN and were dated 11/3/2020. Record #60400: Start of Care 5/27/2021, 6th Benefit Period, Diagnosis COPD, Transfer to another hospice 7/25/2021. The patient clinical record, electronic or paper copies, did not include any signed admission documentation verifying notice of patient rights and hospice election for SOC 5/27/2021. The patient was readmitted to the hospice on 5/27/2021 after revoking service to seek aggressive treatment in the emergency room and hospitalized. The last signed notice of patient rights and signed hospice election statement in the patient’s record were confirmed by the agency RN and were dated 4/27/2021. The agency RN stated that both patients were believed to be “continuing care” in the same benefit period, which would not require new admission documentation, including consents or hospice election.

It is required that criminal background checks are obtained in accordance with state requirements. Agency is to subject state requirement that criminal background checks be obtained prior to the assignment of job role duties. THIS IS A CONTINUING PRIOR REQUIRED ACTION. This standard was not met as evidenced by a review of personnel records and a review of Agency policy. Agency policy, "Selection/Hiring of Personnel," reads in part, "A criminal background check will be obtained for positions, including volunteers, as required by law and regulations.” 1 of 4 (25%) of personnel records reviewed revealed that criminal background checks had not been performed as defined by Agency policy and prior to the assignment of job role duties. Staff ID #37332: AIDE, Date of Hire 7/23/2021- The AIDE's personnel record documented consent for Livescan dated in 2018. The Administrator informed that there were no criminal background check results performed prior to the AIDE's assignment to provide care to patients.